Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Cambridge during CMS and state inspections, most recent first.
Surveyors found that an ice machine in a clean utility room, used to provide ice to residents, had visible white buildup on the sides, a brown streak on the front, and a black mold-like substance on the interior wall. An LPN and the Administrator both confirmed the presence of the black substance and agreed residents should not consume ice from the machine. Review of sanitation logs showed the Maintenance Director had documented twice-monthly inspections and sanitation, while the manufacturer’s manual required cleaning and sanitizing every six months with specific internal areas to be sanitized. The unsanitary condition had the potential to affect all residents receiving ice and was cited as non-compliance under a complaint investigation.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, as evidenced by brown splatters on walls, broken and missing floor tiles, loose floorboards, rusted vents, and resident reports that the building was dirty and poorly maintained. In one shared room, a resident’s bed footboard trim was detached with a two-inch gap, the toilet grout was brown and dirty, the toilet was unstable, and the sharps container was overflowing; these conditions were confirmed by a CNA and an LPN. These environmental issues occurred despite a facility policy requiring a safe, clean, comfortable environment and a physical layout that does not pose safety risks.
Surveyors found that the facility failed to maintain sanitary conditions in the laundry area and an ice machine. The laundry room had only one working washer, numerous barrels of soiled linens and clothing that were uncovered, unbagged, overflowing, and in some cases stored in the hallway, along with a leaking washer and a red hazardous bag placed on top of other laundry. A laundry aide reported that staffing changes left her unable to keep up with laundry volume, leading to backlogs and frequent complaints, and that she bleached all items from red bags because she was not informed of the specific infections involved. The facility’s own infection control policy required soiled linens to be bagged at bedside, securely closed, and stored in a soiled utility room, and prohibited handling improperly bagged linens. Separately, an LPN and the Administrator observed an ice machine with visible buildup and a black mold-like substance inside, despite sanitation logs indicating regular inspections, and the Administrator acknowledged that residents should not consume ice from it.
The facility failed to ensure an ice machine was clean and sanitary, potentially affecting all 76 residents. Observations revealed mold-like areas inside the machine and unclean exterior surfaces. Dietary staff were unaware of a cleaning schedule, and the Administrator confirmed the unsanitary condition.
A resident's missing personal items were not addressed in a timely manner by the facility, despite reports from the resident's representative. The facility failed to log the grievance and did not follow their policy to investigate and resolve the issue within the required timeframe. The resident's personal belongings inventory was not updated, and the facility continued to send the resident's clothing to their laundry room against the family's wishes.
A resident with multiple health issues, including COPD and cognitive impairment, did not receive proper incontinence care due to the facility's failure to provide the correct size briefs. The resident was left in bed for days due to supply shortages, and staff reported ongoing issues with obtaining necessary supplies after a change in the ordering process.
A resident experienced inadequate care due to supply shortages in a facility. The resident, under hospice care for COPD, faced issues with enteral nutrition and incontinence supplies. The facility had to switch her feeding formula due to back orders, and she was provided with improperly sized incontinence briefs, leading to leakage. Staff interviews revealed that supply issues worsened when the corporate office took over ordering, causing delays and shortages.
A resident with chronic pain and a recent sternum fracture did not receive scheduled or as-needed Percocet, leading to uncontrolled pain and requiring an emergent dose. Despite having a care plan and physician orders for pain management, the resident reported not receiving her medication, resulting in severe pain. Staff interviews confirmed the medication was not administered as required, indicating non-compliance with the facility's pain management policy.
The facility failed to address grievances from residents and their representatives, including dietary issues, call light response times, and improper use of equipment. A resident's family reported unresolved issues with meal assistance and medication administration, while another resident experienced inappropriate behavior from a CNA. The facility's inadequate documentation and lack of action led to continued dissatisfaction and unresolved concerns.
The facility failed to prevent the employment of a CNA with a disqualifying felony offense, allowing the individual to work in direct care roles. Despite the CNA's disclosure of a felony conviction on their application, the facility hired them and permitted them to work after a background check confirmed the disqualifying offense. This action was contrary to the facility's policy, which mandates termination for such offenses.
The facility failed to ensure dietary staff competency in food delivery, affecting 72 residents. Issues included late meals, incorrect food items, and inadequate portion sizes. Despite previous citations, problems persisted with meal delivery and food quality. Residents and families reported dissatisfaction with meal times and consistency, leading to non-compliance.
The facility failed to provide meals according to the menu and resident preferences, affecting most residents. Issues included unavailable menu items, incorrect substitutions, and frequent food shortages. Residents reported not receiving ordered items, and the Dietary Manager acknowledged staff communication and inventory management issues.
The facility failed to deliver meals on time, affecting nearly all residents. Staff interviews and observations confirmed frequent delays, with breakfast trays arriving late and meal times varying significantly. Equipment issues in the kitchen, such as a malfunctioning oven, contributed to these delays. Despite recent education on mealtimes, the problem persisted, leading to resident and family dissatisfaction.
A facility failed to protect residents from narcotic misappropriation, involving an agency nurse who improperly documented and administered medications. Discrepancies were found in the administration records for residents prescribed Oxycodone, Ativan, and Percocet. The nurse exhibited impaired behavior, leading to resident complaints and medication errors. Despite a negative drug screen, the facility's investigation was inconclusive due to process breakdowns and documentation issues.
A resident with multiple health conditions reported that an Agency CNA engaged in unwanted political discussions and made derogatory comments about the resident's music preferences during care, despite the resident's requests to stop. The CNA also physically handled the resident in a manner that caused discomfort. The facility's administration was informed, but the incident was not documented in the concern log or progress notes, and the resident felt the issue was not adequately addressed.
The facility failed to investigate allegations of medication misappropriation involving two residents. One resident did not receive all ordered doses of Oxycodone, and discrepancies were found in medication records. Another resident reported not receiving her as-needed Ativan, with a missing tablet noted. The facility's investigation was incomplete, failing to identify these discrepancies, representing non-compliance with regulatory requirements.
A resident with complex medical and behavioral issues was not allowed to return to the LTC facility after an emergency room evaluation, violating the bed-hold policy. The facility issued an immediate discharge notice without adequate preparation or justification, citing safety concerns due to the resident's behaviors. The resident was transferred to a hospital, which did not admit him for psychiatric care, and the facility refused to take him back, leaving the resident without appropriate placement.
A resident with severe cognitive impairment and specific dietary needs was left unattended during meals, leading to another resident attempting to feed her an inappropriate diet. Despite the requirement for substantial assistance and supervision, no staff were present to assist or intervene, as confirmed by the DON.
A resident did not receive prescribed insulin and Lyrica due to facility failures in medication administration and reordering. The insulin was withheld without notifying the provider, and Lyrica was not reordered timely, leading to missed doses. Additionally, the facility lacked a clear policy on medication administration times, causing inconsistencies in medication timing.
A resident with a history of aggressive behavior entered another resident's room unsupervised and threw a drawer at her, causing pain and fear. Both residents were moderately cognitively impaired and dependent on staff for ADLs. The facility's investigation found no willful intent, but the incident revealed a failure in providing adequate supervision and ensuring safety.
The facility failed to consistently provide ice water to residents, affecting their hydration needs. A resident, who was moderately cognitively impaired and dependent on staff, did not have ice water available in her room. Interviews revealed that inconsistent ice water delivery was a common issue, with some residents not receiving it until after 1:00 P.M. The facility's policy requires fresh ice water to be provided each shift, but this was not adhered to, leading to a deficiency finding.
The facility was found to be understaffed, resulting in delayed responses to call lights and inadequate care for residents. Staff and residents reported significant delays, with some waiting over an hour for assistance. Despite conducting call light audits, the facility failed to address the staffing issues, impacting the quality of care provided.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours, affecting all residents. On the specified date, the staffing records showed no RN coverage, only LPNs for both shifts. The Director of Nursing confirmed the absence of an RN, despite visiting the facility for an investigation, as she did not clock in for the required hours. This was against the facility's policy and federal regulations requiring RN presence.
The facility failed to maintain food quality and safety, with meals served at unsafe temperatures and instances of raw pork chops being served to residents. Observations revealed inadequate temperature monitoring, and interviews confirmed frequent resident complaints about food quality, leading some to order food externally. The Dietary Manager's departure followed a resident confrontation, underscoring dissatisfaction with food services.
The facility failed to treat residents with respect and dignity, affecting several individuals. Concerns included staff having cold manners, aides with bad attitudes, and an LPN being rude and dismissive. One resident reported racial remarks from the LPN, while another was forced to come to the door for medication during COVID isolation. The Dietary Manager was also reported to be disrespectful, and a resident was upset by an offensive nickname. These actions violated the facility's policy on customer service.
The facility failed to protect residents from narcotic misappropriation, affecting two residents. One resident's Ativan was signed out by an LPN not on duty, and another resident's Oxycodone was missing. The facility did not report the incidents, and discrepancies in narcotic counts were found. Staff and residents raised concerns about staff working under the influence.
The facility failed to report the misappropriation of narcotics for two residents to the state survey agency within the required timeframe. One resident's Ativan was signed out by an LPN after clocking out, and another resident's Oxycodone was found missing. The facility did not report the incidents as required, and discrepancies in narcotic counts and documentation were noted.
The facility failed to investigate the misappropriation of narcotics affecting two residents. One resident's Ativan was signed out by an LPN after clocking out, and another resident's Oxycodone was missing. Staff reported concerns about the LPN's behavior, but the facility did not report the incidents to the state agency. The facility's policies on abuse and controlled substances were not followed, leading to a breakdown in the reconciliation system.
A facility failed to document and communicate required information during a resident's transfer to an emergency room. The resident, with diagnoses including hallucinations and disorientation, was transferred due to escalating behaviors. The facility's policy required specific information to be communicated to the receiving provider, but there was no documented evidence that this was done, as confirmed by the administrator.
A resident with hallucinations and disorientation was transferred to the hospital without receiving a timely transfer notice, as required by the facility's policy. The facility's policy mandates that such notices include specific reasons for the transfer, appeal rights, and contact information for relevant state entities, but no documented evidence of this notice was found.
A resident with cognitive impairments was transferred to the emergency room due to escalating behaviors, but the facility failed to provide a bed hold notice to the resident or their representative. The facility's policy requires a written notice at the time of transfer, but no documentation was found in the resident's record. The Administrator confirmed the oversight, despite the resident's sister wanting the bed held.
A facility failed to ensure accurate PASARR documentation for a resident with hallucinations and disorientation, leading to an incident of aggression and property damage. The resident's behaviors were not properly addressed, resulting in a transfer to a mental health hospital. This deficiency put the safety of all residents at risk.
A resident with a history of falls and muscle weakness did not have their fall prevention measures implemented as per their care plan. The resident's bed was in a high position, and the required mattress was not on the floor. Additionally, the call light was malfunctioning, and staff were unaware of the resident's fall interventions.
The facility failed to manage narcotic medications properly, affecting all 69 residents. A review showed that staff did not follow the policy requiring a second nurse to witness and sign narcotic count sheets. This was confirmed by an RN and the DON after a nurse noticed a missing blister card of oxycodone, leading to the discovery of nine missing pills. The facility's policy requires narcotics to be counted at each shift change, but this was not adhered to.
A resident with Parkinson's, dysphagia, and gastro-esophageal reflux disease did not receive the prescribed six small mechanical soft meals daily after returning from the hospital with new dietary orders. By late morning, the resident had only received breakfast, and the meal ticket did not reflect the updated order. Both the resident and an RN confirmed the discrepancy, and a staff member was unaware of the new dietary requirement.
A resident with dysphagia and other diagnoses was ordered nectar thickened liquids after failing a swallowing evaluation. However, during a meal observation, the resident was provided with a thin consistency juice, contrary to the order. The DON confirmed the error and removed the incorrect juice.
The facility failed to maintain accurate medication administration records for three residents, leading to discrepancies in narcotic counts. An RN admitted to administering medications without signing them out in the narcotic book, contrary to facility policy. This affected residents with chronic pain, knee pain, and radiculopathy.
A resident with a history of falls and muscle weakness was affected by a non-functional call light at their bedside. Despite the care plan requiring the call light to be within reach, it was observed that the call light did not alert staff when activated. Two staff members passed by without responding, and a nurse's aide confirmed the malfunction. The facility's policy emphasized the need for functional call lights to ensure timely assistance.
A resident with severely impaired cognition and high fall risk fell in the shower room after being instructed by staff to stand up and remove his pants without assistance on a wet floor, resulting in fractures. The resident was not wearing non-skid socks, and the staff member did not have the shower room ready, leading to the fall.
The facility failed to maintain the laundry room in a safe, functional, and sanitary condition, with issues including a non-functioning eyewash station, disassembled washing machine, crumbling drywall, leaking water faucet, and dirty air vents and pallets. These conditions had persisted for some time, as confirmed by a laundry aide and verified by the Regional Maintenance Director.
The facility failed to ensure staff performed proper hand hygiene while distributing meal trays to residents and provided expired milk to a resident. An STNA was observed delivering meal trays without washing or sanitizing her hands, affecting eight residents. Additionally, one resident received expired milk, which was confirmed by the resident and an LPN.
The facility failed to notify physicians of a significant weight change for a resident with severe medical conditions, despite a policy requiring such notification. Interviews confirmed the lack of documentation of physician notification.
The facility failed to update a resident's PASARR document to include a diagnosis of anxiety disorder, despite it being added to the resident's cumulative diagnosis list. This discrepancy was confirmed by the Social Services Designee.
A facility failed to develop a care plan addressing palliative care for a severely cognitively impaired resident with multiple diagnoses, despite a physician order and initial hospice assessment. The MDS nurse confirmed that the facility did not create care plans for palliative care.
The facility failed to update comprehensive care plans for two residents with changes in treatment. One resident's care plan did not reflect the use of methadone for pain management, and another resident's care plan did not include the use of Macrobid for UTIs, despite physician's orders. This was confirmed by facility staff and was against the facility's policies.
The facility failed to provide proper nail care to two dependent residents. One resident had brown material caked under his nails, and another had long nails extending beyond his fingertips. Both residents confirmed they wanted their nails cleaned and trimmed, but staff did not address the issue despite being aware of it.
A resident with severe cognitive impairment and multiple medical conditions was given thin liquids by an STNA despite not having an order for liquids and was not provided the prescribed Magic Cup nutritional supplement. Miscommunication among staff led to the resident not receiving necessary nutritional support.
The facility failed to label, date, and initial an enteral formula for a resident receiving enteral nutrition. An LPN confirmed she did not follow the facility's policy, which requires labeling, dating, and initialing the tube feeding bag to ensure proper administration and monitoring.
The facility failed to ensure a resident's oxygen flow rate was set as ordered by the physician and did not change the humidifier bottle as required. The resident was observed receiving oxygen at four liters per minute instead of the prescribed three liters per minute, and the humidifier bottle had not been changed since the previous month. An LPN confirmed these deficiencies, which affected one of three residents reviewed for respiratory care.
A resident with severe cognitive impairment and multiple medical conditions was provided with a bed with side rails without a proper safety assessment. The resident sustained bruises from hitting the side rails, and the facility failed to follow its policy requiring a comprehensive assessment before using bed rails.
Unsanitary Ice Machine Used for Resident Ice Service
Penalty
Summary
Surveyors identified a deficiency related to unsanitary maintenance of the facility’s ice machine used to provide ice to residents. During an observation of a clean utility room containing the ice machine, surveyors and an LPN noted white streaks of buildup on the sides of the machine, a brown streak on the front, and a black mold-like substance on the upper interior wall of the machine; the LPN confirmed the substance appeared to be mold. The Administrator also observed and confirmed the presence of a black substance in the ice machine and stated that residents should not consume ice from it. Review of the sanitation log completed by the Maintenance Director showed that inspections and sanitation of the ice machine had been documented as completed twice a month since 05/31/25. However, the manufacturer’s manual indicated the machine should be cleaned and sanitized every six months, with specific procedures for sanitizing internal components and consulting a company for more frequent cleaning if needed. The unsanitary condition of the ice machine had the potential to affect all residents receiving ice from the facility. This deficiency represents incidental findings of non-compliance investigated under Complaint Number 2713371.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment on the north unit, affecting multiple residents. During an initial tour, surveyors observed brown splatters on the walls of the north unit. Two residents with diagnoses including type II diabetes, hypertension, thyrotoxicosis, and muscle weakness reported that they felt the facility was not well taken care of and was dirty. Further observation with an LPN confirmed a broken floor tile in the hallway with half of the tile missing and baseboards coming loose. A subsequent tour with the Administrator and DON revealed missing and loose floorboards, additional wall splatters, three vents with rust, and a missing half of a floor tile that was identified as a potential tripping hazard. In a shared room of two other residents with diagnoses including epilepsy, hypo-osmolality and hyponatremia, schizoaffective disorder, and type II diabetes, surveyors observed that the footboard trim on one resident’s bed had come off, leaving an approximately two-inch gap that the resident had unsuccessfully tried to repair with tape. The grout around the toilet in the room was dirty and brown, the toilet itself moved, and the sharps container in the room was overflowing. These conditions were confirmed by both a CNA and an LPN, who acknowledged the gap in the bed footboard trim, the dirty grout, the overflowing sharps container, and the unstable toilet. The facility’s own Safe and Homelike Environment policy required a safe, clean, comfortable, and homelike environment and a physical layout that does not pose a safety risk, which was not met in these observations.
Unsanitary Laundry Practices and Contaminated Ice Machine
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary laundry room and properly manage soiled linens and hazardous laundry, as well as failure to maintain a clean ice machine. Surveyors observed the laundry room, which had a dirty side with washers and a clean side with dryers, and found only one of two washers functional, with 11 barrels of dirty clothing and linens present, one containing a red hazardous bag on the floor. Eight of the barrels were uncovered, contained unbagged linens, and were overflowing, and there was a leak from the washer that left only a narrow walking path to the clean laundry area. Later observation showed 12 full barrels, and a subsequent interview with a laundry aide revealed there were 15 barrels of laundry, including four in the hallway, one without a lid, and multiple barrels in the laundry room without lids, with unbagged, overflowing clothing and linens. The laundry aide reported that second shift had been eliminated, nightshift aides were expected to help but often could not due to other duties, and she could complete only about eight loads per shift, leading to a backlog and frequent complaints. She also stated that red hazardous bags were not accompanied by information about the type of infection, so all items, including personal belongings, were bleached. These practices conflicted with the facility’s infection prevention and control policy, which required soiled linen to be bagged at bedside, securely closed, and placed in the soiled utility room, and specified that environmental services staff should not handle improperly bagged soiled linens. In addition, the facility failed to maintain a sanitary ice machine located in a clean utility room. An LPN and the Administrator observed the ice machine and noted white streaks of buildup on the sides, a brown streak on the front, and a black mold-like substance on the upper interior wall. The Administrator confirmed the presence of a black substance and stated that residents should not consume ice from the machine. Review of the sanitation log showed that the Maintenance Director had documented inspection and sanitation of the ice machine twice a month since a specified date, while the manufacturer’s manual indicated the machine should be cleaned and sanitized every six months, with additional procedures for removing algae or slime using a sanitizing solution on specified internal components followed by rinsing with clear water. These findings were cited as incidental non-compliance under a complaint investigation.
Unsanitary Ice Machine Found in Facility
Penalty
Summary
The facility failed to maintain cleanliness and sanitation of an ice machine, which had the potential to affect all 76 residents. During an observation, brownish-black, mold-like areas were found on the white plastic shield inside the ice machine, and the exterior showed water stains, fingerprints, and dust-like debris. The ice machine was located outside the kitchen in a dining room/common area. Dietary staff confirmed the presence of mold-like areas and were unaware of any cleaning schedule or log for the ice machine. The Administrator also confirmed the unsanitary condition of the ice machine.
Failure to Address Missing Personal Items in a Timely Manner
Penalty
Summary
The facility failed to address reports of missing personal items for a resident in a timely manner, as required by their grievance policy. The resident, who had chronic obstructive pulmonary disease, post-traumatic stress disorder, anxiety disorder, age-related macular degeneration, and bilateral hearing loss, was reported to have missing items including a white/maroon fleece blanket and a gray t-shirt. Despite the resident's representative notifying the facility's Social Service Director (SSD) and sending an email to the management team, the items were not replaced or reimbursed, and the grievance was not logged. The facility's grievance/concern log did not document any reports of missing personal items for the resident, although other residents' missing items were logged. Interviews with staff revealed that the SSD was aware of the missing items but did not ensure they were logged or addressed. The facility's Director of Nursing (DON) acknowledged the email from the resident's representative but did not follow up on the issue. The facility's Administrator confirmed that the missing items were not recorded in the grievance log and that the facility's policy required the family to update the personal inventory list for items brought in after admission. The facility's policy required grievances to be investigated within 72 hours and resolved within seven days, but this was not followed in the case of the missing items. The SSD admitted to forgetting about the issue after initially being informed. The facility's Administrator acknowledged the failure to update the personal belongings inventory sheet and the responsibility to replace missing items known to be in the resident's possession. The facility's corporate policy stated they were not responsible for lost items if the family did the laundry, but the facility continued to send the resident's clothing to their laundry room despite the family's request to handle it themselves.
Inadequate Incontinence Care and Supply Shortages
Penalty
Summary
The facility failed to provide appropriate incontinence care and assistance with daily activities for a resident who was dependent on staff. The resident, who had multiple diagnoses including COPD, cognitive impairment, and was under hospice care, required specific incontinence products and assistance with transfers. However, there were documented instances where the resident was not transferred from bed to chair for two consecutive days, and the facility did not have the correct size incontinence briefs, leading to improper care. Interviews with the resident and her daughter revealed ongoing issues with the availability of proper incontinence supplies. The resident was forced to wear briefs that were too small, resulting in leakage and saturation through her clothing. This issue was not isolated, as it had occurred multiple times since her admission. The facility's central supply employee and CNAs confirmed the supply shortages, noting that the facility had run out of the necessary size briefs and had to resort to makeshift solutions, which were inadequate. The supply issues were attributed to a change in the ordering process, where the corporate office took over the responsibility, leading to communication problems and delays. Staff reported informing management about the shortages, but no immediate solutions were provided, such as purchasing supplies from a store. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with providing necessary care and supplies for the resident.
Supply Shortages Affect Resident Care
Penalty
Summary
The facility failed to maintain sufficient supplies to adequately care for its residents, specifically affecting a resident who required incontinence and enteral tube feeding supplies. The resident, who had multiple medical conditions including COPD and was under hospice care, experienced issues with the availability of her prescribed enteral nutrition. The facility had to switch her feeding formula from Isosource to Jevity due to supply shortages, which was approved by the nurse practitioner. This change was necessitated by the Isosource being on back order, and the resident's daughter confirmed the supply issues were frequent. Additionally, the resident faced problems with the availability of properly sized incontinence briefs. The facility ran out of the correct size, forcing staff to use smaller briefs, which led to leakage and saturation issues. The resident's daughter reported that this had been an ongoing issue, and the resident herself confirmed past incidents of embarrassment due to improper fitting briefs. The facility also experienced a shortage of facial tissues, with the resident's daughter having to bring in supplies from outside. Interviews with staff revealed that the supply issues were exacerbated when the corporate office took over ordering, leading to delays and shortages. The central supply employee and other staff members noted that the corporate office's ordering schedule was less frequent and less responsive to immediate needs compared to when the central supply employee managed orders. The lack of on-site oversight by the corporate office contributed to the mismanagement of supplies, resulting in inadequate care for the residents.
Failure in Pain Management for Resident with Sternum Fracture
Penalty
Summary
The facility failed to implement an effective pain management program for a resident with chronic and acute pain, resulting in actual harm. The resident, who had a history of chronic pain and a recent sternum fracture from a fall, did not receive scheduled or as-needed Percocet as requested. This failure led to uncontrolled pain, affecting the resident's ability to participate in daily activities and necessitating an emergent dose of Percocet to manage the pain. The resident was admitted with multiple diagnoses, including chronic pain and osteoarthritis, and had a care plan that included both pharmacological and non-pharmacological interventions for pain management. Despite having physician orders for scheduled and as-needed Percocet, the resident did not receive the medication as documented. On the day of the incident, the resident reported not receiving her morning medications, including Percocet, which resulted in severe pain rated 10 out of 10. Interviews with staff confirmed the resident's account of not receiving her pain medication, leading to increased pain and the need for a one-time order of Percocet. The facility's policy on pain management emphasized the need for consistent assessment and administration of pain relief, which was not adhered to in this case. The deficiency was investigated under specific complaint numbers, highlighting non-compliance with the facility's pain management policy.
Facility Fails to Address Resident Grievances and Concerns
Penalty
Summary
The facility failed to address and resolve grievances raised by the Ombudsman and resident representatives, affecting all 72 residents. The Ombudsman reported repeated concerns about dietary issues, call light response times, and linen changes, which were not addressed despite multiple meetings. Resident #68's family raised issues about meal assistance, medication administration, and improper use of the Hoyer lift, which remained unresolved over several months. The facility's documentation was inadequate, with no evidence of who attended meetings or what actions were taken to resolve the concerns. Resident #68's care conference notes revealed ongoing issues with meal preferences, medication administration, and staff training on equipment use. The resident's family provided evidence of unmet care needs, such as missing supplements and improper transfers, which were not addressed despite repeated meetings with facility staff. The facility's failure to document and act on these concerns led to continued dissatisfaction and unresolved issues for the resident and their family. Resident #4 reported inappropriate behavior by an Agency CNA, including political discussions and physical discomfort during care. The facility's response focused on the CNA's employment status rather than addressing the resident's concerns about respect and dignity. The lack of documentation and follow-up on the resident's complaints highlights the facility's failure to uphold resident rights and address grievances effectively.
Failure to Prevent Employment of Staff with Disqualifying Offenses
Penalty
Summary
The facility failed to ensure that staff with disqualifying offenses were not permitted to work in direct care roles, which had the potential to affect all 72 residents. An anonymous concern was raised about the employment of staff with criminal backgrounds, prompting an investigation during an onsite complaint survey. A review of a Certified Nursing Assistant's (CNA) application revealed that the CNA had disclosed a felony conviction. Despite this, the CNA was hired and worked in direct care after the background check was completed, which confirmed a disqualifying offense requiring termination. The facility's Bureau of Criminal Identification (BCI) log indicated that the CNA was hired and the background check was submitted on the same day. However, there was no documented evidence of when the BCI report was received, although it was noted as completed later. The CNA worked on two occasions after the background check was completed, despite having a disqualifying offense. The facility's policy stated that individuals with such offenses should not be employed or should be terminated, highlighting a failure to adhere to their own background screening policy.
Dietary Staff Competency and Food Delivery Issues
Penalty
Summary
The facility failed to ensure that dietary staff were competent in carrying out the functions of food delivery, affecting all 72 residents except one who was identified as nothing by mouth (NPO). The concern log from 09/06/24 to 10/31/24 showed 10 reported issues regarding food preferences and receiving food items per order. The food committee meeting minutes from 10/02/24 indicated shortages of wheat bread and snacks. Interviews with residents and staff revealed ongoing issues with food quality, delivery, and availability, despite previous citations in September 2024. Residents reported not receiving meals on time, incorrect food items, and inadequate portion sizes. Observations on 11/05/24 showed discrepancies in the breakfast menu, with missing items like muffins and sausage patties, and substitutions made without proper communication. Staff interviews confirmed frequent late meal deliveries and running out of main food items. The Dietary Manager, who started on 10/01/24, acknowledged issues with the oven and staff not utilizing available resources. Despite recent education provided on mealtimes and food handling, problems persisted with meal delivery and food quality. Residents and their families expressed dissatisfaction with meal times and the consistency of food delivery. Some residents did not receive assistance with meals, and there were reports of incorrect diet textures being provided. The facility's failure to provide adequate food service and maintain dietary standards led to non-compliance, as investigated under Complaint Number OH00159399.
Non-Compliance with Dietary Requirements and Resident Preferences
Penalty
Summary
The facility failed to ensure that meals were provided according to the menu and resident preferences, affecting 71 out of 72 residents who receive meals from the facility kitchen. The concern log from 09/06/24 to 10/31/24 showed 10 reported issues regarding food preferences and receiving food items as ordered. During a breakfast observation on 11/05/24, it was noted that the menu items, including sausage patties and apple muffins, were not available, and substitutions were made without following the residents' preferences. For instance, some residents received bacon instead of sausage patties, and apple cake was served instead of apple muffins. Additionally, a resident who was supposed to receive Fruit Loops was given cornflakes instead, which she found difficult to swallow. Interviews with several residents and a resident's daughter revealed ongoing issues with meal service, including not receiving ordered items, receiving incorrect items, and the kitchen frequently running out of food. One resident reported not receiving a meal tray on one occasion, and another mentioned that her mother, who has trouble swallowing, did not always receive ground meats as required. The Dietary Manager, who started on 10/01/24, acknowledged the issues and noted that staff did not check the freezer for available items or communicate effectively. Despite recent education provided to staff on various aspects of meal service, the concerns persisted, indicating a lack of compliance with dietary requirements and resident preferences.
Untimely Meal Delivery in Facility
Penalty
Summary
The facility failed to ensure that meals were delivered in a timely manner, affecting 71 out of 72 residents who received meals from the facility kitchen. Interviews with various staff members, including an LPN and CNAs, revealed that meal trays were consistently delivered late, with some staff noting that this occurred almost every day. Observations confirmed that breakfast trays arrived late at Southwest Hall, with the Director of Nursing acknowledging the discrepancy between the scheduled and actual delivery times. Residents and their family members also reported variability in meal times, with some meals arriving significantly later than scheduled. The Dietary Manager, who had recently started, identified issues with the kitchen equipment, specifically the malfunctioning oven, which contributed to the delays. Despite providing education on mealtimes, the problems persisted. The facility's mealtime schedule indicated specific times for different halls, but these were not adhered to, leading to complaints and dissatisfaction among residents and their families. The deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with meal delivery standards.
Misappropriation of Narcotics and Medication Errors
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotics, affecting multiple residents. The investigation revealed discrepancies in the administration and documentation of controlled medications, particularly involving an agency registered nurse (ARN #700). This nurse was responsible for administering medications to residents, but there were inconsistencies in the medication administration records (MAR) and controlled drug receipts. For instance, Resident #51 was supposed to receive Oxycodone at specific times, but the records showed discrepancies in the times and quantities administered. Similarly, Resident #56's Ativan administration was not properly documented, and there were missing doses that were unaccounted for. Further investigation into Resident #12's records showed that Percocet was signed out by ARN #700, but the resident did not report any pain or request for pain medication, raising concerns about the legitimacy of the medication administration. Resident #7 also reported not receiving her prescribed Percocet, and there were observations of the nurse behaving inappropriately, such as taking medications from the cart and consuming them herself. These incidents were corroborated by staff and resident interviews, which highlighted the nurse's impaired behavior and the discrepancies in medication counts. The facility's investigation into the self-reported incident (SRI) identified eight residents affected by the misappropriation of narcotics. Despite the nurse's denial of wrongdoing and a negative drug screen, the facility could not conclusively determine the misappropriation due to a breakdown in processes and lack of documentation. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent and document the misappropriation of resident property, leading to significant medication errors and resident complaints.
Resident's Rights to Respect and Dignity Violated by CNA
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, affecting one of the three residents reviewed for this issue. The resident, who had a medical history including lymphedema, diabetes, neuropathy, depression, anxiety, and insomnia, reported that an Agency CNA engaged in unwanted political discussions during care and made derogatory comments about the resident's music preferences. Despite the resident's repeated requests to cease the conversation, the CNA persisted and also physically handled the resident in a manner that caused discomfort and pain by lifting the resident's leg in an unusual and painful position. The resident reported these concerns to the Ombudsman, who communicated them to the facility's administration. The Assistant Director of Nursing (ADON) spoke with the CNA, who acknowledged the conversation but did not perceive it as problematic. The facility's concern log and progress notes lacked documentation of the incident, and the resident felt that the facility did not adequately address the physical discomfort caused by the CNA. The Director of Nursing (DON) later confirmed that the facility completed an abuse investigation, concluding that the incident was not abuse but rather a respect and dignity issue.
Failure to Investigate Medication Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation involving two residents, leading to discrepancies in medication administration. Resident #51, diagnosed with malignant neoplasm of the mouth and tongue, dysphagia, and gastrostomy, was ordered Oxycodone 10 mg every four hours. However, discrepancies were found in the medication administration records and controlled drug receipts, indicating that more doses were signed out than ordered, and some doses were not documented on the MAR. Interviews revealed that the resident did not receive all the doses as signed out, and the facility's investigation did not identify these discrepancies. Resident #56, with diagnoses including depression, PTSD, migraines, sleep apnea, and panic disorder, was ordered Ativan 0.5 mg twice daily and as needed for anxiety. The controlled drug receipts showed a missing Ativan tablet, and the resident reported not receiving her as-needed dose. The facility's investigation failed to identify the missing Ativan and did not include the controlled medication shift change log, which showed discrepancies in the medication count and lack of reconciliation when the agency nurse left. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of such incidents, but the investigation was incomplete and did not thoroughly address the discrepancies in medication administration for both residents. The facility's failure to identify and investigate these discrepancies represents non-compliance with regulatory requirements.
Facility Failed to Permit Resident's Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after an emergency room evaluation, violating the bed-hold policy. The resident, who had a history of encephalopathy, hallucinations, and other complex medical conditions, was initially readmitted to the facility but exhibited challenging behaviors such as wandering, aggression, and non-compliance with medication. Despite these behaviors, the facility did not provide adequate notice or preparation for the resident's discharge, which was executed on an emergency basis without sufficient justification. The resident's behaviors included impulsivity, aggression, and wandering, which were documented in progress notes. The facility attempted to manage these behaviors with medication adjustments and one-on-one supervision, but the interventions were not given adequate time to determine their effectiveness. The facility issued an immediate discharge notice, citing safety concerns, and transferred the resident to a hospital without a court order or proper discharge planning. The hospital did not admit the resident for psychiatric care, as he did not meet the criteria for admission, and the facility refused to take him back, leaving the resident without appropriate placement. The hearing officer found that the facility did not comply with state regulations regarding discharge notice and preparation. The facility failed to demonstrate that an emergency existed to justify the immediate discharge and did not provide evidence of a comprehensive care plan to address the resident's behavioral issues. The resident's sister and the hospital social worker confirmed that the facility did not assist in finding alternative placement, resulting in the resident remaining in the hospital until a new facility was found.
Failure to Supervise and Assist Resident During Meals
Penalty
Summary
The facility failed to provide necessary assistance and supervision during meal times for Resident #62, who was admitted with multiple diagnoses including traumatic subarachnoid hemorrhage, dysphagia, and Alzheimer's. The resident required substantial assistance with eating due to severe cognitive impairment and was on a mechanically altered diet with a feeding tube. Despite these needs, observations revealed that Resident #62 was left unattended during lunch in a dining area, with no staff present to assist or supervise. This lack of supervision allowed another resident to attempt to feed Resident #62 a regular diet, which was inappropriate given her dietary restrictions. The deficiency was further highlighted by the absence of staff intervention, as the Certified Nurse's Aide (CNA) did not notice or encourage the residents to eat, and the Director of Nursing (DON) confirmed the lack of supervision. The DON acknowledged that Resident #62 should not have been left unattended, especially given her dietary needs and the requirement for supervision during meals. The facility's failure to ensure proper supervision and assistance during meals for Resident #62 represents a significant lapse in care, as documented by the surveyor's observations and interviews.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were readily available and administered as ordered, affecting a resident who was admitted with diagnoses including diabetes and neuropathy. On a specific date, the resident did not receive their prescribed insulin at bedtime due to low blood sugar, but there was no evidence that the provider was notified or that there were orders to hold the medication. Additionally, the resident reported not receiving other medications, including a nasal spray and a drink, and an agency nurse was subsequently educated and removed from providing care to the resident. However, there was no evidence of an investigation into the possible medication error. Further issues were identified when the resident did not receive their prescribed Lyrica for neuropathy pain on another date. The facility's records showed that the medication was not available for administration because staff failed to reorder it in a timely manner. The Director of Nursing confirmed that the medication was not reordered until the morning of the missed dose, resulting in the medication not being available for administration. The facility also lacked a clear policy on medication administration times, leading to inconsistencies in the timing of medication administration. The resident's Lyrica was administered at times that did not align with the prescribed schedule, and there was confusion about the allowable time frames for medication administration. Interviews with facility staff and the pharmacist revealed discrepancies in understanding and implementing medication administration times, contributing to the deficiency.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to prevent an altercation between two residents, resulting in a deficiency related to inadequate supervision and accident prevention. Resident #3, who was moderately cognitively impaired and dependent on staff for activities of daily living, was involved in an incident where another resident, Resident #4, entered her room and threw a drawer at her leg. Resident #3 had a history of multiple fractures and other medical conditions, and at the time of the incident, she experienced pain and fear due to the altercation. Resident #4, also moderately cognitively impaired, had a history of hallucinations, aggressive behaviors, and was on one-to-one monitoring due to ongoing behavioral issues. Despite these precautions, Resident #4 was unsupervised at the time of the incident and entered Resident #3's room, leading to the altercation. The facility's investigation revealed that Resident #4 had no recollection of the event and was unable to communicate effectively about it. The facility's self-reported incident indicated that the altercation was unsubstantiated as abuse due to the lack of willful intent and significant injury. However, the incident highlighted a failure in providing adequate supervision and ensuring a safe environment for residents, as Resident #4's behaviors were known and had previously been a concern for staff and resident safety.
Inconsistent Ice Water Delivery to Residents
Penalty
Summary
The facility failed to ensure that residents received ice water in their rooms as per their preferences and needs, which is essential for maintaining hydration. This deficiency was identified through observations, interviews, and record reviews. Specifically, Resident #3, who was moderately cognitively impaired and dependent on staff for activities of daily living, did not have ice water available in her room during an observation. The resident expressed a desire to have ice water, indicating a lapse in the facility's hydration practices. Interviews with an ombudsman and another resident revealed that the issue of inconsistent ice water delivery was a common concern among residents. The Assistant Director of Nursing confirmed receiving complaints from both staff and residents about the irregular provision of ice water, sometimes not being delivered until after 1:00 P.M. The facility's policy, dated November 2018, mandates that State-tested Nursing Assistants provide fresh ice water to residents each shift, with additional deliveries as needed. This deficiency was investigated under Complaint Number OH00158883.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by multiple interviews and reviews of resident council minutes and concern logs. Staff and residents reported that the facility was understaffed, leading to delays in answering call lights and providing timely care. One staff member mentioned that with only one aide per hall, it was challenging to provide incontinence care and respond to call lights promptly. Residents expressed similar concerns, noting that there was only one aide per unit, which was insufficient given the number of residents. Several residents reported significant delays in receiving assistance, with call light response times ranging from 15 minutes to over an hour. One resident mentioned having to wait two to four hours during the night shift for assistance, while another resident recounted an incident where they were told to urinate on themselves and wait for staff to return. Additionally, a medical care provider observed a 20-minute delay in call light response during a visit, further corroborating the residents' complaints. The facility's concern log and resident council minutes highlighted ongoing issues with staffing, particularly on weekends, where response times were reportedly slower. Despite conducting call light audits, the facility did not address the underlying staffing issues. The facility's policies emphasized the importance of timely call light responses and customer service, but these were not effectively implemented, leading to the deficiency.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a registered nurse (RN) for at least eight consecutive hours on 08/04/24, potentially affecting all 69 residents. A review of the facility's daily staff posting for that date showed a census of 64, with no RN or RN hours recorded for either the dayshift or nightshift. Instead, there were 3.75 Licensed Practical Nurses (LPNs) for 44 hours on the dayshift and 2.75 LPNs for 32 hours on the nightshift. The staffing schedule and time sheets for 08/04/24 also showed no evidence of an RN being scheduled or having worked that day. An interview with the Director of Nursing (DON) confirmed the absence of an RN for the required hours, despite the DON visiting the facility to investigate missing narcotics, as she did not clock in and could not confirm being present for eight hours. The facility's policy, dated 10/2017, states that sufficient staff should be provided to meet resident care plans and facility assessments, which was not adhered to on the specified date. The facility assessment, revised on 08/29/24, indicated that one to four RNs should be present daily, with federal regulations requiring 0.55 hours per resident day (HPRD) from RNs.
Deficiency in Food Quality and Safety
Penalty
Summary
The facility failed to ensure that food was palatable, attractive, and served at a safe and appetizing temperature, potentially affecting all 69 residents. During an observation, it was noted that the mechanical soft chicken patty and pureed chicken patty on the steam table were below the required holding temperature of 135 degrees Fahrenheit, measuring at 117.8 and 115.1 degrees Fahrenheit, respectively. The Dietary Manager from a sister facility acknowledged the issue, noting that the steam table knobs were missing, and the temperature setting was unknown. Additionally, food temperature logs revealed that temperatures were not consistently recorded for all meals on specific dates, and the cook admitted to not checking holding temperatures before meal service. Further issues were identified when a photo showed residents being served raw pork chops, with interviews confirming that four residents ingested the undercooked meat. Multiple residents and staff reported frequent concerns about food quality, including cold meals, raw meat, and generally poor food quality, leading some residents to order food from outside sources. One resident reported weight loss due to the poor quality of food, necessitating supplements. The Dietary Manager reportedly quit after a confrontation with a resident, highlighting ongoing dissatisfaction with the facility's food services.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, affecting four residents out of nine reviewed. Concerns submitted to the state survey agency highlighted several incidents where staff exhibited disrespectful behavior towards residents. Specific instances included staff having cold manners, aides displaying bad attitudes, and a Licensed Practical Nurse (LPN) being rude and dismissive towards residents. One resident reported that the LPN made racial remarks and was not allowed in his room. Another resident mentioned that the LPN refused to enter her room to administer medication while she was in isolation for COVID, forcing her to come to the door instead. Interviews with residents and staff corroborated these concerns. A resident reported that the Dietary Manager was disrespectful when asked for alternative meals, and another resident witnessed the Dietary Manager slamming a door in response to complaints about food quality. Additionally, a resident expressed distress over being called a nickname she found offensive. The facility's policy on customer service emphasized treating residents with respect and dignity, which was not adhered to in these instances. This deficiency was investigated under multiple complaint numbers.
Misappropriation of Resident Narcotics
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotics, affecting two residents. Resident #51, who had diagnoses including anxiety, insomnia, dementia, and depression, was prescribed Ativan for anxiety/agitation. An LPN signed out Ativan for Resident #51 at a time when he was not on duty, and there was no evidence of the medication being administered as scheduled. Interviews revealed that the LPN had a history of administering narcotics without signing them off on the Medication Administration Record (MAR), and the Director of Nursing (DON) was unaware of these discrepancies. Resident #42, with diagnoses including radiculopathy and low back pain, was prescribed Oxycodone for pain management. An anonymous complaint raised concerns about the LPN working under the influence and misappropriating medications. The facility discovered that nine Oxycodone tablets were missing, but did not report the incident as the resident did not miss a dose and the medication was replaced. The facility's investigation was unable to determine the cause of the missing medication, and there were discrepancies in the narcotic count and control sheets. The facility's policies on abuse and controlled substances were not followed, as the misappropriation of resident property was not reported to the appropriate authorities. The facility's failure to conduct a thorough investigation and report the incidents to the state agency contributed to the deficiency. Interviews with staff and residents indicated concerns about staff working under the influence and the misappropriation of medications, highlighting a breakdown in the facility's reconciliation system.
Failure to Report Misappropriation of Narcotics
Penalty
Summary
The facility failed to report the misappropriation of resident narcotics to the state survey agency within the required timeframe, affecting two residents. Resident #51, who had diagnoses including anxiety and dementia, was prescribed Ativan for anxiety/agitation. A discrepancy was found when LPN #198 signed out Ativan after clocking out, and there was no evidence of the medication being signed off on the MAR. Interviews revealed that LPN #198 had a pattern of administering narcotics without signing them off, and the facility was unaware of the narcotic-related issue due to a lack of investigation. Resident #42, with diagnoses including radiculopathy and low back pain, was prescribed Oxycodone for pain. An anonymous complaint raised concerns about LPN #198's behavior and potential drug influence. The facility discovered nine missing Oxycodone tablets but did not report the incident as the resident did not miss a dose, and the medication was replaced. The facility's investigation was unable to determine the cause of the missing medication, and discrepancies in narcotic counts and documentation were noted. The facility's policies required immediate reporting of misappropriation to the state agency, but this was not done. The investigation revealed a breakdown in the reconciliation system, with staff failing to follow proper procedures for counting and documenting narcotics. The facility's failure to report the incidents and conduct a thorough investigation led to non-compliance with regulatory requirements.
Failure to Investigate Misappropriation of Narcotics
Penalty
Summary
The facility failed to thoroughly investigate the misappropriation of resident narcotics, affecting two residents. Resident #51 was admitted with diagnoses including anxiety, insomnia, dementia, depression, and senile degeneration of the brain. The medical record review revealed discrepancies in the administration of Ativan, a controlled drug. LPN #198 signed out Ativan at 3:30 A.M., despite clocking out at 2:00 A.M. Interviews with staff indicated that LPN #198 often administered narcotics without signing them off on the MAR, and the DON was unaware of these issues. The facility did not conduct an investigation as they were not aware the issue was narcotic-related. Resident #42, admitted with diagnoses including radiculopathy and cervical disc degeneration, was prescribed Oxycodone for pain. An anonymous complaint raised concerns about LPN #198's behavior, suggesting he might be under the influence of drugs. The facility reported missing Oxycodone but did not report the incident to the state agency, as the resident did not miss a dose and the medication was replaced. The facility's investigation revealed that LPN #198 had removed an empty narcotic sheet and placed it in the shred box, but the facility could not determine what happened to the missing Oxycodone. The facility's policies on abuse and controlled substances were not followed, as the misappropriation of narcotics was not reported to the appropriate authorities. The facility's failure to ensure accurate narcotic counts and documentation led to a breakdown in the reconciliation system. Interviews with staff and residents indicated concerns about staff working under the influence, and the facility's investigation was limited to only three nurses who had access to the cart. The facility did not audit all medication carts, and there was no evidence of a comprehensive investigation into the missing narcotics.
Failure to Document and Communicate Required Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that all required information was communicated and documented during the transfer of a resident to another healthcare provider. This deficiency was identified through a closed medical record review, staff interviews, and policy review. Specifically, the facility did not provide the necessary documentation and information to the receiving healthcare facility when a resident was transferred to the emergency room. The resident in question had been admitted with diagnoses including hallucinations and disorientation, and was transferred due to escalating behaviors and concerns for safety. The facility's policy required that specific information be communicated to the receiving provider during a transfer, including contact information of the responsible practitioner, resident status, advance directives, diagnoses, allergies, medications, and other relevant medical information. However, upon review, there was no documented evidence that this information was provided for the resident's transfer. The facility's administrator confirmed the lack of documentation, which was a violation of the facility's transfer and discharge policy.
Failure to Provide Timely Transfer Notification
Penalty
Summary
The facility failed to provide timely notification to a resident and their representative before transferring the resident to the hospital. The deficiency was identified during a closed medical record review, staff interview, and policy review. The resident, who had been admitted with diagnoses including hallucinations and disorientation, was transferred to the emergency room due to escalating behaviors. Despite the transfer, there was no documented evidence that a transfer notice was provided to the resident or their representative, as required by the facility's policy. The facility's policy mandates that a transfer/discharge notice be provided to the resident, their representative, and the ombudsman as soon as practicable before the transfer or discharge. This notice should include specific reasons for the transfer, the effective date, location, appeal rights, and contact information for relevant state entities. However, in this case, the facility did not adhere to its policy, resulting in a deficiency related to the lack of proper notification for the resident's transfer to the hospital.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident and their representative when the resident was transferred to the emergency room. This deficiency was identified during a closed medical record review, staff interview, and policy review. The resident, who had been admitted with diagnoses including hallucinations, disorientation, and other cognitive symptoms, was transferred to the emergency room due to escalating behaviors and safety concerns. Despite the transfer, there was no documented evidence that the resident or their representative received the required bed hold notice. The facility's policy mandates that a written notice specifying the duration of the bed-hold policy be provided to the resident or representative at the time of transfer. In cases of emergency transfers, the notice should be given within 24 hours. However, the review of the resident's closed medical record revealed no such documentation. An interview with the Administrator confirmed the absence of the bed hold notice, although the resident's sister had expressed a desire to hold the bed. This deficiency was investigated under Complaint Number OH00156733.
Inaccurate PASARR Documentation and Resident Safety Risk
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASARR) documents accurately reflected the resident's diagnoses. This deficiency was identified during a closed medical record review, staff interviews, and policy review. The resident in question was admitted with diagnoses including hallucinations and disorientation, yet the PASARR dated shortly after admission indicated no serious mental illness. This discrepancy was significant as the resident exhibited behaviors consistent with their diagnoses, including agitation and aggression, which led to an incident where the resident caused property damage and required emergency intervention. The facility's failure to secure accurate PASARR documentation and ensure proper care for the resident put the safety and security of all residents at risk. The resident's history of combative and delusional behaviors was not adequately addressed, leading to a situation where the resident was transferred to an inpatient mental health hospital for stabilization. The facility's policy on coordinating assessments with the PASARR program was not effectively implemented, resulting in non-compliance as investigated under a specific complaint number.
Failure to Implement Fall Interventions for At-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident at risk of falls, identified as Resident #51. The resident had a history of falls, a healed traumatic fracture, and muscle weakness. The resident's care plan included specific fall prevention measures such as a soft call light, ensuring the call light was within reach, a low bed, and a full mattress on the floor beside the bed. However, during an observation, the resident's bed was found in a high position, and the full mattress was not placed on the floor as required. Additionally, the call light was not functioning properly, as it did not alert staff when activated. The surveyor noted that two staff members walked by the resident's room without responding to the activated call light. A State tested Nurse's Aide (STNA) confirmed the malfunction of the call light and admitted to being unaware of the resident's fall interventions due to being a float STNA. The STNA subsequently placed the mattress on the floor and lowered the bed. The Director of Nursing and registered nurses later confirmed the resident's care plan requirements and acknowledged the failure to adhere to the fall prevention measures.
Failure in Narcotic Medication Management
Penalty
Summary
The facility failed to ensure proper management of narcotic medications, which could potentially affect all 69 residents. A review of the narcotic control sheets and interviews with staff revealed that the facility did not follow its policy requiring a second nurse to witness and sign when narcotic medication count sheets were added or removed from the inventory. This lapse in procedure was confirmed during an interview with an RN and the DON. The issue came to light when a nurse noticed a change in the color of a resident's blister pack of oxycodone and discovered that the previous blister card and control sheet were missing, with several pills unaccounted for. The facility's policy mandates that narcotics be counted at the beginning and end of each shift by both the on-coming and off-going nurses, with any discrepancies reported immediately to the DON. However, this procedure was not followed, leading to the discovery of nine missing oxycodone pills.
Failure to Provide Prescribed Diet to Resident
Penalty
Summary
The facility failed to ensure a resident received their diet as ordered, affecting one resident out of three records reviewed. Resident #41, who was admitted with diagnoses including Parkinson's, dysphagia, and gastro-esophageal reflux disease, returned from the hospital with new orders for six small mechanical soft meals daily and aspiration precautions after failing a swallowing evaluation. Despite these orders, the resident had only received one meal by 11:41 A.M. on 08/28/24, which was breakfast. The meal ticket did not reflect the new order for six small meals daily. Both the resident and RN #206 confirmed the resident had not been receiving the prescribed six small meals. Additionally, staff member #151 was unaware of the new dietary order and confirmed that only one meal had been sent to the resident that day.
Failure to Provide Ordered Nectar Thickened Liquids
Penalty
Summary
The facility failed to ensure a resident received fluids as ordered, affecting one resident. The resident was admitted with diagnoses including Parkinson's disease, dysphagia, and gastro-esophageal reflux disease. After returning from the hospital, the resident had new orders for nectar thickened liquids and aspiration precautions due to failing a swallowing evaluation. However, during an observation of the resident's dinner meal, it was noted that the resident had a thin consistency red juice on the meal tray, contrary to the nectar thickened liquid order. The meal ticket indicated the correct order, but the provided juice did not comply with the order. The Director of Nursing confirmed the discrepancy and removed the incorrect juice from the tray.
Medication Administration Record Discrepancies
Penalty
Summary
The facility failed to ensure the completeness and accuracy of resident medical records, specifically medication administration records and narcotic administration records, affecting three residents. Resident #37, admitted with chronic pain syndrome and a neurostimulator, had discrepancies in the count of Oxycodone tablets between the medication cart and the controlled drug receipt form. Similarly, Resident #31, with diagnoses including knee pain and diabetes, had inconsistencies in the count of Oxycodone and Ativan tablets. Resident #42, admitted with conditions such as radiculopathy and low back pain, also had a discrepancy in the Oxycodone tablet count. During an observation, RN #129 admitted to administering medications to these residents but failed to sign them out in the narcotic book at the time of administration. This was confirmed by RN #206, who noted that the administration records did not match the times the medications were reportedly given. The facility's policy requires signing the Medication Administration Record (MAR) and the narcotic book after administration, and any discrepancies should be corrected and reported to the nurse manager. These findings were part of an investigation under Complaint Number OH00156496.
Non-Functional Call Light at Resident's Bedside
Penalty
Summary
The facility failed to ensure that a resident's call light was functional at the bedside, affecting a resident with a history of falls and muscle weakness. The resident, who had been admitted with diagnoses including a history of falls and a healed traumatic fracture, had a care plan that required a soft call light to be within reach at all times. Despite this, an observation revealed that the call light was not functioning properly, as it did not light up to alert staff when activated. During the survey, it was noted that two staff members walked by the resident's room without responding to the activated call light. A state-tested nurse's aide later confirmed the malfunction, indicating that the call light outside the room was not lighting up. The facility's policy on call lights, dated April 2022, emphasized the importance of having a functional call light at each resident's bedside to ensure timely assistance. This deficiency was identified during an investigation under a specific complaint number.
Failure to Implement Fall Interventions and Provide Adequate Assistance
Penalty
Summary
The facility failed to ensure fall interventions were implemented and residents were provided the appropriate level of assistance to prevent falls. This deficiency affected a resident with severely impaired cognition who required physical assistance for lower body dressing and was identified as a high fall risk. The resident fell in the shower room after being instructed by staff to stand up and remove his pants without assistance on a wet floor, resulting in a displaced, comminuted fracture of the left radius and a displaced fracture of the right ulna styloid process. The resident's care plan included interventions such as ensuring the call light was always within reach and wearing non-skid footwear while out of bed. However, during the incident, the resident was not wearing non-skid socks, and the floor was wet. The staff member involved admitted to not having the shower room ready before bringing the resident in and instructed the resident to remove his pants without providing the necessary assistance. This led to the resident losing balance and falling. Interviews with staff and review of documentation revealed inconsistencies in the accounts of the incident. The STNA initially stated the resident was not wearing non-skid socks and the floor was wet, but later changed her statement. The DON confirmed that the STNA should have had the shower room ready and assisted the resident with removing his pants. The facility's fall prevention policy was not adequately followed, contributing to the resident's fall and subsequent injuries.
Laundry Room Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the laundry room in a safe, functional, and sanitary condition, potentially affecting all 68 residents. Observations revealed multiple issues: a non-functioning eyewash station, a disassembled washing machine, a large hole in the wall beside the hot water tank, crumbling drywall with large holes, a leaking water faucet overflowing onto the floor, and air vents covered with a greyish substance and debris, including a leaf sticking out of one vent. Additionally, there was a drainage pipe with significant dirt buildup underneath and detergent pellets stored on dirty pallets. An interview with a laundry aide confirmed that these conditions had persisted for some time. The Regional Maintenance Director later verified all findings except for the eyewash station, which had been fixed by the time of the interview.
Failure to Perform Proper Hand Hygiene and Provide Fresh Milk
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene while distributing meal trays to residents. During an observation, a State Tested Nursing Assistant (STNA) was seen delivering meal trays to eight residents without washing or sanitizing her hands at any point. This was confirmed by the STNA during an interview. The facility's policy on hand hygiene, which requires handwashing or the use of hand sanitizer before and after assisting a resident with meals, was not followed. This affected eight residents who ate their meals in their rooms on the Northwest Unit. Additionally, the facility failed to ensure that residents were not provided with milk that was past its best-by date. One resident was found with expired milk on his breakfast tray, which he had not consumed. The resident confirmed that the milk was expired, and this was verified by a Licensed Practical Nurse (LPN). The resident's medical record indicated multiple diagnoses, including human immunodeficiency virus disease, atrial fibrillation, and chronic obstructive pulmonary disease, among others. The facility census was 68, with 67 residents receiving food from the facility kitchen.
Failure to Notify Physician of Significant Weight Change
Penalty
Summary
The facility failed to notify physicians of significant weight changes for a resident, which is a requirement according to their policy. Resident #50, who had multiple severe medical conditions including anoxic brain injury, malnutrition, and dysphagia, experienced a significant weight loss of 6.06% over one month. Despite this, there was no documentation in the medical record indicating that the physician was informed of this significant weight change. Interviews with the dietitian and the Regional Director of Clinical Services confirmed that there was no evidence of physician notification regarding the resident's weight loss. The facility's policy mandates informing the resident, consulting with the physician, and notifying the resident's family or legal representative when there are significant changes in the resident's condition. This policy was not followed in the case of Resident #50, leading to the identified deficiency.
Inaccurate PASARR Documentation
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) documents for a resident accurately reflected their diagnoses. Specifically, the PASARR document for a resident admitted with diagnoses including dementia with agitation, bipolar disorder, cognitive communication deficit, and alcohol abuse with encephalopathy did not include the diagnosis of an anxiety disorder, which was added to the resident's cumulative diagnosis list at a later date. This discrepancy was confirmed during an interview with the Social Services Designee, who acknowledged that the PASARR document should have been updated to reflect the resident's current diagnoses.
Failure to Develop Palliative Care Plan
Penalty
Summary
The facility failed to develop a care plan that addressed palliative care for a resident. The resident, who was admitted with multiple diagnoses including unspecified protein-calorie malnutrition, depression, atherosclerotic heart disease, spinal stenosis, adult failure to thrive, low back pain, cognitive communication deficit, osteoarthritis, anxiety disorder, and unspecified dementia, was severely cognitively impaired according to a comprehensive MDS assessment. Despite an initial palliative assessment being completed by hospice and a physician order for hospice palliative care, the resident's care plan did not address palliative care. An interview with the MDS nurse confirmed that the facility did not create care plans specifically for palliative care, leading to this deficiency.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive resident care plans were updated with changes in treatment for two residents. Resident #32, who has diagnoses including paraplegia, hypertensive heart disease, and chronic kidney disease, had a care plan that did not reflect the use of methadone for pain management despite a physician's order dated 12/16/23. This was confirmed by both an LPN and the Director of Nursing during interviews. The facility's policy on pain management required that interventions for pain management be incorporated into the comprehensive care plan, which was not done in this case. Similarly, Resident #33, with diagnoses including chronic kidney disease, severe protein-calorie malnutrition, and acute on chronic diastolic heart failure, had a care plan that was not updated to include the use of Macrobid for recurrent urinary tract infections, despite a physician's order dated 01/03/24. This was confirmed by the Regional Director of Operations. The facility's policy on comprehensive care plans required the development and implementation of a person-centered care plan that included measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this instance.
Failure to Provide Proper Nail Care to Dependent Residents
Penalty
Summary
The facility failed to provide proper nail care to two dependent residents, Resident #23 and Resident #32. Resident #23, who has severe cognitive impairment and is dependent on staff for personal hygiene, was observed on multiple occasions with brown material caked underneath the nailbeds of all fingers. Despite the resident's confirmation that he would like his nails cleaned and trimmed, the issue was not addressed by the staff. Licensed Practical Nurse (LPN) #144 confirmed the presence of the brown substance under the resident's nails during an interview. Resident #32, who has moderately impaired cognition and is also dependent on staff for personal hygiene, was observed with long fingernails extending beyond the tips of his fingers. The resident confirmed that he had asked the staff to cut his nails, but they had not done so. State-tested Nursing Assistant (STNA) #151 and LPN #168 both confirmed that the resident's nails were long and needed trimming. The facility's policy requires a nurse to trim the nails of diabetic residents, but this was not adhered to in the case of Resident #32.
Failure to Follow Dietary Orders and Provide Nutritional Supplements
Penalty
Summary
The facility failed to ensure that a resident who was not supposed to receive liquids by mouth was not provided liquids by mouth and failed to ensure nutritional supplements were provided as ordered. Resident #50, who had severe cognitive impairment and multiple medical conditions including anoxic brain injury, dysphagia, and a gastrostomy, was observed being given thin liquids by a State tested Nursing Assistant (STNA) despite not having an order for liquids. The resident was observed holding the liquid in her mouth, which then leaked down the sides of her mouth, indicating she could not tolerate it. Additionally, the resident's tray ticket did not include the prescribed nutritional supplement, Magic Cup, which was confirmed by multiple staff members during interviews. The medical record review revealed that Resident #50 had a pureed texture diet order and was to receive one cold item at each meal, with no order for liquids. The resident's plan of care included providing supplements as ordered and monitoring her weight, which indicated she was underweight. Despite this, the resident had not been receiving the Magic Cup supplement as ordered. Interviews with staff, including the Dietary Manager and Speech Therapist, revealed confusion and miscommunication regarding the resident's dietary needs and the provision of the Magic Cup supplement. The Dietary Manager reported that the kitchen had not been sending the Magic Cup because the Speech Therapist had recommended only one cold item per meal, which was misunderstood to exclude the supplement. The Speech Therapist confirmed that the resident should not receive any liquids by mouth and that the recommendation for one item per meal was due to the resident's quick fatigue. The Dietitian was unaware that the Magic Cup was not being provided and expected it to be the cold item at meals. This miscommunication and failure to follow dietary orders led to the resident not receiving the necessary nutritional support and being given inappropriate liquids by mouth.
Failure to Label, Date, and Initial Enteral Formula
Penalty
Summary
The facility failed to label, date, and initial an enteral formula for a resident receiving enteral nutrition. This deficiency was identified during a medical record review, observation, and staff interview. Specifically, Resident #62, who had multiple diagnoses including acute dilation of the stomach, partial intestinal obstruction, and dysphagia, was observed with a tube feeding bag that was not labeled, dated, or initialed. The tube feeding was infusing at a rate of 60 ml/hr, and the disposable enteral feeding bag lacked necessary information to ensure proper administration and monitoring. During an interview, an LPN confirmed that she had hung the tube feeding bag for Resident #62 but had not labeled, dated, or initialed it. The facility's policy requires that the nurse label the formula, document their initials, and write the date and time the formula was hung. The LPN acknowledged that she did not follow this protocol. The facility's policy also mandates that the information on the tube feeding bag be checked against the physician's order, which was not adhered to in this instance.
Failure to Ensure Proper Oxygen Flow Rate and Humidifier Maintenance
Penalty
Summary
The facility failed to ensure that Resident #32's oxygen flow rate was set as ordered by the physician and did not change the humidifier bottle as required. Resident #32, who has a history of paraplegia, hypertensive heart disease, transient ischemic attack, cerebral infarction, hypoxemia, diabetes mellitus, and chronic kidney disease, was observed receiving oxygen at four liters per minute instead of the prescribed three liters per minute. Additionally, the humidifier bottle attached to the oxygen concentrator was empty and had not been changed since 04/08/24, despite the facility policy requiring it to be changed every 72 hours or as recommended by the manufacturer. During an interview, an LPN confirmed that the oxygen flow rate was incorrect and that the humidifier bottle had not been changed as required. The facility's policy on oxygen administration states that oxygen should be administered under physician orders and that humidifier bottles should be changed when empty, every 72 hours, or as recommended by the manufacturer. This deficiency affected one of the three residents reviewed for respiratory care, with a total of seven residents receiving oxygen therapy in the facility, which has a census of 68 residents.
Failure to Assess Bed Rail Safety
Penalty
Summary
The facility failed to assess a resident for the safe use of bed rails prior to their implementation. Resident #50, who had severe cognitive impairment and multiple medical conditions including anoxic brain injury, malnutrition, and contractures, was provided with a bed that had side rails without a proper safety assessment. The resident's medical record from the period when the bed rails were in use did not include a side rail assessment, which is a requirement according to the facility's policy on the proper use of bed rails. On 04/26/24, during routine rounds, a State tested Nursing Assistant (STNA) observed new bruising on Resident #50's right hand, left cheek, and above the left eyebrow. The bruising was consistent with the resident hitting her face and hand on the side rail of the bed. The facility's investigation revealed that the bruising was caused by the resident rolling onto her left side and coming into contact with the side rail. The interdisciplinary team decided to pad the side rails to prevent further injury. The Director of Nursing (DON) confirmed that a bed rail assessment should have been completed when the resident received the new bed with side rails. However, this assessment was not conducted, leading to the resident sustaining injuries. The facility's policy requires a comprehensive assessment considering various factors such as medical conditions, cognition, and risk of falling before the use of bed rails, which was not followed in this case.
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What surveyors actually found near you
We read the 176 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cambridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Cambridge Inc. | 1.3 mi | ★★★★★ | 14 | 0 |
| The Enclave At Cambridge | 3.1 mi | ★★★★★ | 20 | 0 |
| Continuing Healthcare At Beckett House | 9.1 mi | ★★★★★ | 2 | 0 |
| Riverside Manor Nrsg & Rehab Ctr | 15.8 mi | ★★★★★ | 4 | 0 |
| Lafayette Pointe Nursing & Rehab Ctr | 18 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.